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Gaps in Referral to Bariatric Surgery for Patients with Type 2 Diabetes seen in Endocrinology Clinics

  • Author Footnotes
    ∗ equally contributed to manuscript writing as co-primary authors
    Sheila Holmes
    Footnotes
    ∗ equally contributed to manuscript writing as co-primary authors
    Affiliations
    University Health Network, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON

    Women’s College Hospital, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON
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  • Author Footnotes
    ∗ equally contributed to manuscript writing as co-primary authors
    Shohinee Sarma
    Footnotes
    ∗ equally contributed to manuscript writing as co-primary authors
    Affiliations
    Sinai Leadership Centre for Diabetes, Mount Sinai Hospital, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON
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  • Sara Campbell
    Affiliations
    Sunnybrook Health Sciences Centre, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON
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  • Abdulrahman Azab
    Affiliations
    Women’s College Hospital, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON
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  • Judy Qiang
    Affiliations
    Sunnybrook Health Sciences Centre, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON
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  • Geetha Mukerji
    Correspondence
    Correspondence: Geetha Mukerji, Women's College Hospital, Department of Endocrinology, 3rd Floor, 76 Grenville St., Toronto ON M5S 1B2
    Affiliations
    Women’s College Hospital, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON

    Women’s College Hospital Institute for Health System Solutions and Virtual Care; 76 Grenville Street, Toronto ON, Canada, M5S 1B2
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  • Author Footnotes
    ∗ equally contributed to manuscript writing as co-primary authors
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      Abstract:

      Objective

      One in three adults in Canada are overweight and 26.8% experience obesity.1 Bariatric surgery confers effective weight loss and reduces obesity-related complications including Type 2 diabetes,2 but remains an underutilized treatment.3,4,5 Our objective was to determine whether a referral gap exists in bariatric program referrals for patients with Type 2 diabetes seen in endocrinology clinics at an ambulatory tertiary care hospital in Toronto, Canada.

      Methods

      A retrospective chart review was conducted of 843 consecutive patients with type 2 diabetes in endocrinology clinics between January 1, 2015 and December 31, 2020. Inclusion criteria included adult patients with Type 2 diabetes and body mass index (BMI) >35 kilograms per square-metre (kg/m2). Exclusion criteria included recent active cancer, uncontrolled psychiatric disease, or active substance use disorder within 6 months of the initial visit. Referrals to bariatric surgery were assessed within a 5-year follow-up period and compared to baseline referral rates from the Ontario Bariatric Network (OBN). An online survey of 48 Endocrinologists in Toronto, Ontario was also conducted to assess physician-level barriers to referral.

      Results

      Patients with Class II obesity (BMI >35 kg/m2) and Type 2 diabetes meeting eligibility criteria for bariatric referral was 4.6% (n=38) (Figure 1). A documented discussion about bariatric surgery occurred with seven (18.0%) of these eligible patients and 1 patient (2.6%) was referred for surgery. Aside from surgical referrals, only 2.6% of eligible patients were referred to cognitive behavioural therapy (CBT), 36.8% were initiated on obesity pharmacotherapy, and 42.1% were referred to a dietician. Baseline OBN data demonstrated that most surgical referrals (n=6360) were from family physicians (65.0%) and only 8.8% were from a medicine specialist (Table 1). Eight percent of surveyed endocrinologists reported that they discussed bariatric surgery with at least half of their eligible patients. The most frequent barrier to discussing bariatric surgery during visits was time constraints. Physicians identified that simplifying the referral process and providing bariatric surgery handouts would be helpful interventions to improve referral rates.

      Conclusion

      Our gap analysis demonstrated a low bariatric surgery referral rate by tertiary care endocrinologists. Our study also found a large gap in the appropriate treatment of obesity with poor utilization of behavioural, lifestyle, and pharmacotherapy practices. As obesity and diabetes rates increase, better education, training, and knowledge translation is necessary to overcome weight bias and prioritize obesity management.

      Keywords

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